TBRHSC Patient Safety Indicators

Nine separate indicators will be reported on, including a number of hospital-related infections and the success rates of health care professionals practicing proper hand hygiene to prevent the spread of disease.

The public reporting of safety indicator rates is not intended to serve as a measure for hospitals to compare themselves against other organizations, or for the public to use as a measure of where to seek care. Rates can vary from hospital to hospital, month to month. Some hospitals may experience higher specific rates due to the nature of the care they provide and their patient population, such as those with higher elderly patient populations.

What public reporting adds and ensures is that all hospitals are tracking and counting in the same way. This is not for comparison purposes, but rather for accountability. Our posting the data on our website confirms TBRHSC’s commitment to public accountability and transparency. A further benefit is that hospitals with similar demographics and challenges can more easily share tips and strategies.

Indicator	Reporting Period	Data	Trend
Central-Line Primary Blood Stream Infection (CLI)	Jan/2012 to March/2012	CLI rate = 0.0 (per 1000 central line days)	Trend
Clostridium Difficile Infection (CDI)	April 2012	# new cases of hospital-acquired CDI < 5 rate of C. difficile per 1,000 patient days: 0.0	Trend
Hand Hygiene Compliance	April/2011 to March 2012	hand hygiene compliance before initial patient/environment contact = 51%	Trend
Hand Hygiene Compliance	April/2011 to March 2012	hand hygiene compliance after patient/environment contact = 61%	Trend
Hospital Standardized Mortality Ratio (HSMR)	2010-2011	ratio of observed to expected deaths: 72	Trend
Methicillin Resistant Staphylococcus Aureus (MRSA)	Jan/2012 to March/2012	# of cases hospital-acquired MRSA bacteraemia: 0 rate of MRSA per 1,000 patient days: 0.05	Trend
Surgical Safety Checklist	Jan/11 to Jun/11	SSC Rate = 96.92%	Trend
Surgical Site Infection Prevention	Jan/2012 to March/2012	SSI Prevention Rate = 95.4%	Trend
Vancomycin Resistant Enterococcis (VRE)	Jan/2012 to March/2012	# of cases hospital-acquired VRE bacteraemia: 0 rate of VRE per 1,00 patient days: 0	Trend
Ventilator-Associated Pneumonia (VAP)	Jan/2012 to March/2012	VAP rate = 3.72 (per 1000 ventilator days)	Trend

TBRHSC is committed to the process of continuous improvement and believes:

Our hospitals are safe, the care you receive here is top-notch and every effort is being made to ensure you receive safe, high quality care
We look forward to working with our health care professionals to make necessary improvements over time
Our dedicated health care professionals are committed to providing the best possible care to our patients
Our hospital strongly supports the provincial government’s new public reporting regime because we believe it will inspire improved performance, enhance patient safety, and strengthen the public’s confidence in Ontario’s hospitals

Additional information regarding these indicators and provincial trends may be found on the Ministry of Health and Long-Term Care website.

If you have any questions about our hospital's patient safety indicators, please contact:

Cathy Covino
Senior Director - Quality and Risk Management
Thunder Bay Regional Health Sciences Centre
Phone: (807) 684-6012
Email: covinoc@tbh.net